Consultative Examinations: A Guide for Health Professionals

Part IV - Adult Consultative Examination Report Content Guidelines

The following are guidelines for minimum content requirements for CE reports on adult claimants. Each DDS will notify medical sources of any additional requirements.

General Consultative Examination and Report
  1. General
    1. Identify claimant
      1. Include the claimant’s claim number, and
      2. Indicate that the claimant provided proof of identity by showing a valid and current government photo ID (e.g., U.S. State-issued driver’s license, U.S. State-issued non-driver identity card, U.S. passport, U.S. military ID, student or school ID, etc.) or
      3. Provide a physical description of the claimant, to help ensure that the person being examined is the claimant, except if the treating source is the CE source. 
    2. Longitudinal medical history
      1. Cite the medical records and any other documents reviewed during the course of the evaluation.
      2. Identify the person(s) providing the oral medical history and an assessment of the validity and reliability of such information.

  2. Current Medical History – Describe and discuss (when appropriate):
    1. The primary symptom(s) alleged as the reason for not working. This discussion must include:
      1. History of the onset and progress of the disorder;
      2. The claimant's statement of current symptom(s);
      3. Type and resultant effect of any treatment;
      4. Claimant’s typical daily activities.
    2. Dates and results of relevant hospitalizations, surgical operations, and diagnostic procedures.

  3. Past Medical History – Describe and discuss (when appropriate) other significant past illnesses, injuries, operations, and diagnostic procedures with dates of the events.

  4. Current Medication – List name, dose and frequency of medication(s), including both beneficial and adverse effects; and plans for continued drug administration, schedule and extent of any therapy.
     
  5. Review of Systems – Describe and discuss:
    1. Other symptoms the claimant has experienced relative to any specific organ systems;
    2. The pertinent negative findings considered in making a differential diagnosis of the current illness or in evaluating the severity of this or any other alleged impairment.
       
  6. Social History – Include pertinent findings about use of tobacco products, alcohol, nonprescription drugs, etc.
     
  7. Family History – Include relevant information.

  8. Physical Examination – Describe and discuss (when appropriate):  General appearance; nutritional status (including height and weight without shoes); behavior (such as cooperativeness); and, any apparent abnormalities. 
  1. Interpretation of laboratory tests (If the interpretation is provided separately, the report sheet should state the interpreting medical source's name and address)

    1. Identify the medical source (name and address) providing the formal interpretation of the laboratory tests when that source is other than the individual signing the CE report.
    2. Provide interpretation of laboratory results that takes into account, and correlates with, the history and physical examination findings.

  2. Imaging tests (for example, x-rays) and other laboratory tests – Obtain only after proper authorization from the DDS.

  3. Medical source statement – The consultative examiner must assess the claimant’s abilities and limitations based upon the claimant’s medical history, observations during the examination, and results of relevant laboratory tests. The medical source statement should specify the nature and extent of the condition or disorder. It must also discuss any apparent discrepancies in the medical history or in the examination findings. Finally, the statement must specify any limitations in function that result from the condition or disorder, including:
  • Lifting/carrying/pushing/pulling
  • Sitting/standing/walking
  • Posture (for example, climbing/stooping/bending/balancing/crawling/ kneeling/crouching)
  • Fine motor skills (that is, handling/fingering/gripping/feeling)
  • Overhead and forward reaching
  • Vision/hearing/speech
  • Environmental exposures (for example, heat/cold/humidity/noise/vibration)

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Report Content by Specific Impairment
 

Musculoskeletal System

(Boldface type indicates additional requirements not found in the General Report)

  1. General
    1. Identify claimant
      1. Include the claimant’s claim number, and
      2. Indicate that the claimant provided proof of identity by showing a valid and current government photo ID (e.g., U.S. State-issued driver’s license, U.S. State-issued non-driver identity card, U.S. passport, U.S. military ID, student or school ID, etc.) or
      3. Provide a physical description of the claimant, to help ensure that the person being examined is the claimant, except if the treating source is the CE source. 
    2. Longitudinal medical history
      1. Cite the medical records and any other documents reviewed during the course of the evaluation.
      2. Identify the person(s) providing the oral medical history and an assessment of the validity and reliability of such information.

  2. Current Medical History – Describe and discuss (where appropriate):
    1. The primary symptom(s) alleged as the reason for not working. This discussion must include:
      1. History of the onset and progress of the disorder;
      2. The claimant's statement of current symptom(s);
      3. Type and resultant effect of any treatment;
      4. The claimant’s typical daily activities.
    2. Dates and results of relevant hospitalizations, surgical operations, and diagnostic procedures (for example, x-ray, myelography, CT scan, MRI, bone scan).

  3. Past Medical History – Describe and discuss (when appropriate) other significant past illnesses, injuries, operations, and diagnostic procedures with dates of the events. Describe the claimant’s prior typical daily activities.

  4. Current Medication – List name, dose and frequency of medication(s), including both beneficial and adverse effects.
     
  5. Review of Systems – Describe and discuss:
    1. Other symptoms the claimant has experienced relative to any specific organ systems;
    2. The pertinent negative findings that would be considered in making a differential diagnosis of the current illness or in evaluating the severity of this or any other alleged impairment.
       
  6. Social History – Include pertinent findings about use of tobacco products, alcohol, nonprescription drugs, etc.
     
  7. Family History – Include relevant information.

  8. Physical Examination – Describe and discuss (when appropriate):
    1. General appearance, nutritional status (including height and weight without shoes), behavior (such as cooperativeness), any apparent abnormalities such as gait or the need for any type of assistive device;
    2. Extremities and peripheral joints – deformity; tenderness; active range of motion; grip, pinch, and extremity strength (either by dynamometer or 0 – 5 scale); atrophy; ability to use, and effective use, of any orthotic device;
    3. Spine – distribution of pain, tenderness, sensory or motor loss; intensity and symmetry of deep tendon reflexes; active range of spinal motion; straight-leg raising (lumbar spine, both sitting and supine) and Spurling Test (cervical spine);
    4. Amputated extremities – description of stump, including integrity of skin flap; tenderness; ability to use, and effective use, of any prosthetic device;
    5. Fractures of bones of extremities or pelvis – imaging and clinical evidence of union or non-union;
    6. Soft tissue injuries/burns – nature and extent; skin sensitivity; effect on joint motion.

  9. Interpretation of laboratory tests - (If the interpretation is provided separately, the report sheet should state the interpreting medical source's name and address)
    1. Identify the medical source (name and address) providing the formal interpretation of the laboratory tests when that source is other than the individual signing the CE report.
    2. Provide interpretation of laboratory results that takes into account, and correlates with, the history and physical examination findings.

  10. Imaging tests (for example, x-rays) or other laboratory tests – Obtain only after proper authorization from the DDS.

  11. Medical source statement – The consultative examiner must assess the claimant’s abilities and limitations based upon the claimant’s medical history, observations during the examination, and results of relevant laboratory tests. The medical source statement should specify the nature and extent of the condition or disorder. It must also discuss any apparent discrepancies in the medical history or in the examination findings. Finally, the statement must specify any limitations in function that result from the condition or disorder, including:
  • Lifting/carrying/pushing/pulling
  • Sitting/standing/walking
  • Posture (for example, climbing/stooping/bending/balancing/crawling/ kneeling/crouching)
  • Fine motor skills (that is, handling/fingering/gripping/feeling)
  • Overhead and forward reaching
  • Vision/hearing/speech
  • Environmental exposures (for example, heat/cold/humidity/noise/vibration)
  • Traveling

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Special Senses and Speech

   Visual Impairments

   (Boldface type indicates additional requirements not found in the General     Report)

  1. General
    1. Identify claimant
      1. Include the claimant’s claim number, and
      2. Indicate that the claimant provided proof of identity by showing a valid and current government photo ID (e.g., U.S. State-issued driver’s license, U.S. State-issued non-driver identity card, U.S. passport, U.S. military ID, student or school ID, etc.) or
      3. Provide a physical description of the claimant, to help ensure that the person being examined is the claimant, except if the treating source is the CE source.
    2. Longitudinal medical history
      1. Cite the medical records and any other documents reviewed during the course of the evaluation.
      2. Identify the person(s) providing the oral medical history and an assessment of the validity and reliability of such information.

  2. Current Ocular History – Describe and discuss (when appropriate):
    1. The primary symptom(s) alleged as the reason for not working. This discussion must include:
      1. History of the onset and progress of the disorder;
      2. The claimant's statement of current symptom(s);
      3. Type and resultant effect of any treatment;
      4. Claimant’s typical daily activities.
    2. Dates and results of relevant hospitalizations, surgical operations, and diagnostic procedures (for example, imaging studies, visual acuity and visual field measurements).

  3. Past Medical History – Describe and discuss other significant past illnesses, injuries, operations, and diagnostic procedures with dates of the events (if related to the ocular history).

  4. Current Medication – List name, dose and frequency of medication(s) for the ocular disorder(s), including both beneficial and adverse effects.
     
  5. Review of Systems – Describe and discuss if relevant to the ocular disorder.
  1. Social History – Include only if relevant to ocular disorder.
     
  2. Family History – Include relevant information.

  3. Physical Examination – Describe and discuss (when appropriate):
    1. Best corrected visual acuity for each eye, and the lens correction for each eye.
    2. Examination of pupils, external exam, extraocular motions, and confrontation visual fields.
    3. If confrontation fields are not normal, or if there is a history of glaucoma, visual fields are needed. Confrontation fields are acceptable evidence that the fields are normal, but restricted fields must be confirmed either by Goldmann or Humphrey 30-2 fields. If there is a neurologic field defect, and Goldmann fields are not available, Humphrey kinetic is useful.
    4. Intraocular pressure for each eye.
    5. Slit lamp exam: cornea and lens at least
    6. Fundus exam: discs, vessels, and maculae, and peripheral retina.
    7. If there is a loss of visual acuity or visual fields, the cause of the loss should be documented in the report.  If the vision loss is due to a cortical visual disorder, it must be confirmed by documenting the cause of the brain lesion.
  1. Interpretation of laboratory tests (If the interpretation is provided separately, the report sheet should state the interpreting medical source's name and address)
    1. Identify the medical source (name and address) providing the formal interpretation of the laboratory tests when that source is other than the individual signing the CE report.
    2. Provide interpretation of laboratory results that takes into account, and correlates with, the history and physical examination findings.

  2. Imaging tests (for example, x-rays) and other laboratory tests – Obtain only after proper authorization from the DDS.

  3. Additional Information – include a printout of any visual field test results.

  4. Medical source statement – The consultative examiner must assess the claimant’s abilities and limitations based upon the claimant’s medical history, observations during the examination, and results of relevant laboratory tests. The medical source statement should specify the nature and extent of the condition or disorder. It must also discuss any apparent discrepancies in the medical history or in the examination findings. Finally, the statement must specify any limitations in function that result from the condition or disorder, including:
  • Lifting/carrying/pushing/pulling
  • Sitting/standing/walking
  • Posture (for example, climbing/stooping/bending/balancing/crawling/ kneeling/crouching)
  • Fine motor skills (that is, handling/fingering/gripping/feeling)
  • Overhead and forward reaching
  • Vision/hearing/speech
  • Environmental exposures (for example, heat/cold/humidity/noise/vibration)
  • A summary opinion from the consultative examiner that the recorded acuities and fields can reasonably be expected to result from the medical condition of the person, and any other relevant observations, (Example: the person who claims five degree fields, but walks around without difficulty).
  • A description of the claimant’s cooperation with the visual examination should be noted.

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   Hearing Impairments

   (Boldface type indicates additional requirements not found in the General     Report)

  1. General
    1. Identify claimant
      1. Include the claimant’s claim number, and
      2. Indicate that the claimant provided proof of identity by showing a valid and current government photo ID (e.g., U.S. State-issued driver’s license, U.S. State issued non-driver identity card, U.S. passport, U.S. military ID, student or school ID, etc.) or
      3. Provide a physical description of the claimant, to help ensure that the person being examined is the claimant, except if the treating source is the CE source.
    2. Longitudinal medical history
      1. Cite the medical records and any other documents reviewed during the course of the evaluation.
      2. Identify the person(s) providing the oral medical history and an assessment of the validity and reliability of such information.

  2. Current Medical History – Describe and discuss (when appropriate):
    1. The primary symptom(s) alleged as the reason for not working. This discussion must include:
      1. History of the onset and progress of the disorder;
      2. The claimant's statement of current symptom(s);
      3. Type and resultant effect of any treatment;
      4. Claimant’s typical daily activities.
    2. Dates and results of relevant hospitalizations, surgical operations, and diagnostic procedures (for example, audiometry, tympanography, MRI).
    3. Air and bone pure tone audiogram and speech audiograms to include speech reception thresholds and speech discrimination scores, copy of the audiogram, OAEs, ABRs, tympanograms, CTs of the head and tympanic bones, MRIs of the head, and the audiologist’s testing result comments.
    4. Labyrinthine-vestibular disorders should include documentation of episodes of vertigo, including frequency, severity and duration of the attacks.

  3. Past Medical History – Describe and discuss (when appropriate) other significant past illnesses, injuries, operations, and diagnostic procedures with dates of the events.

  4. Current Medication – List name, dose and frequency of medication(s), including both beneficial and adverse effects.
     
  5. Review of Systems – Describe and discuss:
    1. Other symptoms the claimant has experienced relative to any specific organ systems;
    2. The pertinent negative findings considered in making a differential diagnosis of the current illness or in evaluating the severity of this or any other alleged impairment.
       
  6. Social History – Include pertinent findings about use of tobacco products, alcohol, nonprescription drugs, etc.
     
  7. Family History – Include relevant information.

  8. Physical Examination – Describe and discuss (when appropriate):
    1. General appearance, nutritional status (including height and weight without shoes), behavior (such as cooperativeness), any apparent abnormalities;
    2. Otolaryngologic examination, pure tone air and bone audiometry, and speech audiometry, including speech reception threshold (SRT) and speech discrimination testing; examination of the ears, nose and throat for the evaluation of a hearing impairment or disturbance of labyrinthine-vestibular function.  The otologic examination should describe the pinna, external auditory canals and tympanic membranes.  For Vertigo, report the presence or absence of nystagmus, Romberg results, and cerabellar signs. 

  9. Interpretation of laboratory tests (If the interpretation is provided separately, the report sheet should state the interpreting medical source's name and address)
    1. Identify the medical source (name and address) providing the formal interpretation of the laboratory tests when that source is other than the individual signing the CE report.
    2. Provide interpretation of laboratory results that takes into account, and correlates with, the history and physical examination findings.
    3. For vertigo, include results of ENGs, caloric tests, and any balance tests that have been performed and available from acceptable medical sources.
  1. Imaging tests (for example, x-rays) and other laboratory tests – Obtain only after proper authorization from the DDS.

  2. Medical source statement – The consultative examiner must assess the claimant’s abilities and limitations based upon the claimant’s medical history, observations during the examination, and results of relevant laboratory tests. The medical source statement should specify the nature and extent of the condition or disorder. It must also discuss any apparent discrepancies in the medical history or in the examination findings. Finally, the statement must specify any limitations in function that result from the condition or disorder, including:
  • Lifting/carrying/pushing/pulling
  • Sitting/standing/walking
  • Posture (for example, climbing/stooping/bending/balancing/crawling/ kneeling/crouching)
  • Fine motor skills (that is, handling/fingering/gripping/feeling)
  • Overhead and forward reaching
  • Vision/hearing/speech
  • Environmental exposures (for example, heat/cold/humidity/noise/vibration)

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Respiratory System

(Boldface type indicates additional requirements not found in the General Report)

  1. General
    1. Identify claimant
      1. Include the claimant’s claim number, and
      2. Indicate that the claimant provided proof of identity by showing a valid and current government photo ID (e.g., U.S. State-issued driver’s license, U.S. State-issued non-driver identity card, U.S. passport, U.S. military ID, student or school ID, etc.) or
      3. Provide a physical description of the claimant, to help ensure that the person being examined is the claimant, except if the treating source is the CE source.
    2. Longitudinal medical history
      1. Cite the medical records and any other documents reviewed during the course of the evaluation.
      2. Identify the person(s) providing the oral medical history and an assessment of the validity and reliability of such information.

  2. Current Medical History – Describe and discuss (when appropriate):
    1. The primary symptom(s) alleged as the reason for not working. This discussion must include:
      1. History of the onset and progress of the disorder;
      2. The claimant's statement of current symptom(s), especially dyspnea (at rest or only with exertion).  Exertional capacity should be addressed in both situations, such as how far the claimant can walk before resting; presence of any associated symptoms, such as palpitation, wheezing, cough, sputum production, chest discomfort, symptoms of hyperventilation, paroxysmal nocturnal dyspnea, or orthopnea;
      3. Description of severe respiratory attack(s) or persistent pulmonary infection.
      4. Type and resultant effect of any treatment;
      5. Claimant’s typical daily activities.
    2. Dates and results of relevant hospitalizations, surgical operations, and diagnostic procedures.

  3. Past Medical History – Describe and discuss (when appropriate) other significant past illnesses, injuries, operations, and diagnostic procedures with dates of the events.

  4. Current Medication – List name, dose and frequency of medication(s), including both beneficial and adverse effects.
     
  5. Review of Systems – Describe and discuss:
    1. Other symptoms the claimant has experienced relative to any specific organ systems;
    2. The pertinent negative findings considered in making a differential diagnosis of the current illness or in evaluating the severity of this or any other alleged impairment.
    3. History of heart disease.
       
  6. Social History – Include pertinent findings about use of tobacco products, alcohol, nonprescription drugs, etc. Report any employment history that is relevant to the disease, such as exposure to chemicals, irritants, etc., that produced respiratory symptoms.
     
  7. Family History – Include relevant information.

  8. Physical Examination – Describe and discuss (when appropriate):
    1. General appearance, nutritional status (including height and weight without shoes), behavior (such as cooperativeness), any apparent abnormalities;
    2. The vital signs must include blood pressure, pulse rate and rhythm, respiratory rate (and whether unlabored or labored, and if there is use of accessory muscles of respiration)
    3. Lungs
      1. Occurrence of cough, audible wheezing, pallor cyanosis, hoarseness, clubbing of fingers, chest wall deformity, any abnormal curvature of the spine
      2. Whether there is prolongation of the exhalatory phase of respiration
      3. Breath sounds (that is, air exchange), and presence or absence of adventitious sounds (such as rhonchi or rales)
      4. Diaphragmatic motion
    4. Heart and vascular
      1. Description of heart sounds
      2. Presence of any lifts, heaves, or thrills
      3. Heart size
      4. Point of maximal impact of cardiac apex
      5. Presence of any murmurs, rubs or gallops
      6. Presence and location of any bruits
      7. Distention of neck veins
      8. Presence, type, and extent of any peripheral edema and any associated skin discoloration or ulceration
  1. Interpretation of laboratory tests (If the interpretation is provided separately, the report sheet should state the interpreting medical source's name and address)
    1. Identify the medical source (name and address) providing the formal interpretation of the laboratory tests when that source is other than the individual signing the CE report.
    2. Provide interpretation of laboratory results that takes into account, and correlates with, the history and physical examination findings.

  2. Imaging tests (for example, x-rays) and other laboratory tests (for example, Diffusing Capacity of the Lungs for Carbon Monoxide –DLCO) – Obtain only after proper authorization from the DDS.

  3. Additional Information – Pulmonary Function Tests 
    1. Spirometry and DLCO tracings must be provided when these tests have been performed. 
    2. The reported findings for pulmonary function tests must meet the requirements of Section 3.00E of the Listing of Impairments (see  http://www.ssa.gov/disability/professionals/bluebook/3.00-Respiratory-Adult.htm).
    3. A statement should be made regarding the individual’s ability to understand the directions, as well as the effort and cooperation in performing the pulmonary function test(s).

  4. Medical source statement – The consultative examiner must assess the claimant’s abilities and limitations based upon the claimant’s medical history, observations during the examination, and results of relevant laboratory tests. The medical source statement should specify the nature and extent of the condition or disorder. It must also discuss any apparent discrepancies in the medical history or in the examination findings. Finally, the statement must specify any limitations in function that result from the condition or disorder, including:
  • Lifting/carrying/pushing/pulling
  • Sitting/standing/walking
  • Posture (for example, climbing/stooping/bending/balancing/crawling/ kneeling/crouching)
  • Fine motor skills (that is, handling/fingering/gripping/feeling)
  • Overhead and forward reaching
  • Vision/hearing/speech
  • Environmental exposures (for example, heat/cold/humidity/noise/vibration)

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Cardiovascular System

(Boldface type indicates additional requirements not found in the General Report)

  1. General
    1. Identify Claimant
      1. Include the claimant’s claim number, and
      2. Indicate that the claimant provided proof of identity by showing a valid and current government photo ID (e.g., U.S. State-issued driver’s license, U.S. State-issued non-driver identity card, U.S. passport, U.S. military ID, student or school ID, etc.) or
      3. Provide a physical description of the claimant, to help ensure that the person being examined is the claimant, except if the treating source is the CE source.
    2. Longitudinal medical history
      1. Cite the medical records and any other documents reviewed during the course of the evaluation. State whether the DDS provided medical documents for review.
      2. Identify the person(s) providing the oral medical history and an assessment of the validity and reliability of such information.

  2. Current Medical History – Describe and discuss (when appropriate):
    1. The primary symptom(s) alleged as the reason for not working. This discussion must include:
      1. History of the onset and progress of the disorder;
      2. The claimant's statement of current symptom(s);
      3. Type and resultant effect of any treatment;
      4. Claimant’s typical daily activities;
      5. Degree of limitation, if any, in the ability to independently initiate, sustain, or complete activities of daily living;
      6. For chronic heart failure, the claimant’s statement of current symptoms, especially dyspnea, orthopnea and fatigue;
      7. For ischemic heart disease, the claimant’s statement of current symptoms, especially chest pain (angina, angina equivalents, or variant angina) and reduced cerebral perfusion (for example, confusion, difficulty walking); the quality, location, radiation, and duration of the pain should be noted along with factors that exacerbate the pain (e.g., continued activity, deep breathing, etc.), or relieve it (e.g., rest, nitroglycerin, food, etc.).  Also, any concomitant symptoms such as SOB, diaphoresis, nausea, dizziness, or lightheadedness should be noted.
      8. For arrhythmias, the claimant’s statement of current symptoms, especially a description of dizziness, near syncope, and syncope;
      9. For peripheral vascular disease, the claimant’s statement of current symptoms, especially intermittent claudication, swelling and skin changes in the lower extremities.
    2. Dates and results of relevant hospitalizations, surgical operations, and diagnostic procedures (for example, electrocardiography, exercise-tolerance stress testing, angiography, echocardiography, and any other imaging studies).

  3. Past Medical History – Describe and discuss (when appropriate) other significant past illnesses, injuries, operations, and diagnostic procedures with dates of the events.

  4. Current Medication – List name, dose and frequency of medication(s), including both beneficial and adverse effects.
     
  5. Review of Systems – Describe and discuss:
    1. Other symptoms the claimant has experienced relative to any specific organ systems.
    2. The pertinent negative findings considered in making a differential diagnosis of the current illness or in evaluating the severity of this or any other alleged impairment.
       
  6. Social History – Include pertinent findings about use of tobacco products, alcohol, nonprescription drugs, etc.
     
  7. Family History – Include relevant information.
  8. Physical Examination – Describe and discuss (when appropriate):
    1. General appearance, nutritional status (including height and weight without shoes), behavior (such as cooperativeness), any apparent abnormalities;
    1. The vital signs must include blood pressure (taken supine, sitting, and standing), pulse rate and rhythm, respiratory rate (and whether unlabored or labored, and if there is use of accessory muscles of respiration);
    2. Lungs
      1. Occurrence of cough, audible wheezing, pallor cyanosis, hoarseness, clubbing of fingers, chest wall deformity, any abnormal curvatures of the spine;
      2. Whether there is prolongation of the exhalatory phase of respiration;
      3. Breath sounds, and presence or absence of adventitious sounds (such as rhonchi or rales);
      4. Diaphragmatic motion;
    3. Heart and vascular
      1. Presence of any lifts, heaves, or thrills;
      2. Heart size;
      3. Point of maximal impact of cardiac apex;
      4. Presence of any murmurs, rubs or gallops;
      5. Presence and location of any bruits;
      6. Distention of neck veins;
      7. Presence, type, and extent of any peripheral edema and any associated skin discoloration or ulceration in the extremities;
      1. Quality of peripheral pulses in extremities;
      2. Presence and quality of carotid pulses;
      3. Presence of any abdominal pulsation and/or bruit should be noted.
  1. Interpretation of laboratory tests (If the interpretation is provided separately, the report sheet should state the interpreting medical source's name and address)
    1. Identify the medical source (name and address) providing the formal interpretation of the laboratory tests when that source is other than the individual signing the CE report.
    2. Provide interpretation of laboratory results that takes into account, and correlates with, the history and physical examination findings.

  2. Imaging tests (for example, x-rays) and other laboratory tests – Obtain only after proper authorization from the DDS.
  1. Additional Information – Electrocardiogram (ECG) & Exercise Tolerance Tests (ETT)
    1. ECG tracings must be provided when these tests have been performed 
    2. The reported findings for electrocardiograms must meet the requirements of Section 4.00C of the Listing of Impairments (see http://www.ssa.gov/disability/professionals/bluebook/4.00-Cardiovascular-Adult.htm).
    1. On rare occasions, it may be necessary to request an exercise tolerance test (ETT). The physician supervising the ETT will make the final decision as to whether the claimant’s medical condition will allow him or her to tolerate safely the stress involved.
  1. Medical source statement – The consultative examiner must assess the claimant’s abilities and limitations based upon the claimant’s medical history, observations during the examination, and results of relevant laboratory tests. The medical source statement should specify the nature and extent of the condition or disorder. It must also discuss any apparent discrepancies in the medical history or in the examination findings.  The summary should note the claimant’s cardiovascular symptoms and signs with an evaluation of whether or not the findings are consistent with the presence of cardiovascular disease.  Finally, the statement must specify any limitations in function that result from the condition or disorder, including:
  • Lifting/carrying/pushing/pulling
  • Sitting/standing/walking
  • Posture (for example, climbing/stooping/bending/balancing/crawling/ kneeling/crouching)
  • Fine motor skills (that is, handling/fingering/gripping/feeling)
  • Overhead and forward reaching
  • Vision/hearing/speech
  • Environmental exposures (for example, heat/cold/humidity/noise/vibration)

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Digestive System

(Boldface type indicates additional requirements not found in the General Report)

  1. General
    1. Identify claimant
      1. Include the claimant’s claim number, and
      2. Indicate that the claimant provided proof of identity by showing a valid and current government photo ID (e.g., U.S. State-issued driver’s license, U.S. State-issued non-driver identity card, U.S. passport, U.S. military ID, student or school ID, etc.) or
      3. Provide a physical description of the claimant, to help ensure that the person being examined is the claimant, except if the treating source is the CE source.
    2. Longitudinal medical history
      1. Cite the medical records and any other documents reviewed during the course of the evaluation.
      2. Identify the person(s) providing the oral medical history and an assessment of the validity and reliability of such information.

  2. Current Medical History – Describe and discuss (when appropriate):
    1. The symptom(s) alleged as the reason for not working. This discussion must include:
      1. History of the onset and progress of the disorder;
      2. The claimant's statement of current symptom(s) especially fatigue, muscle weakness, sensory aberrations, cognitive impairment, malaise, loss of appetite; sleep disturbance and any other nocturnal symptoms; nausea; recent (involuntary) weight loss and the amount;
      3. Type and effect of any treatment;
      4. Claimant’s typical daily activities.
    2. Dates and results of relevant hospitalizations, surgical operations, and diagnostic procedures (for example, diagnostic imaging, endoscopy, biopsy, aspiration of ascitic fluid, clinical laboratory tests, arterial blood gases).

  3. Past Medical History – Describe and discuss (when appropriate) other  past illnesses, injuries, operations, and diagnostic procedures with dates of the events.

  4. Current Medication – List name, dose and frequency of medication(s), including both beneficial and adverse effects.
     
  5. Review of Systems – Describe and discuss:
    1. Other symptoms the claimant has experienced relative to any specific organ systems;
    2. The pertinent negative findings considered in making a differential diagnosis of the current illness or in evaluating the severity of this or any other alleged impairment.
       
  6. Social History – Include pertinent findings about use of tobacco products, alcohol, nonprescription drugs, etc.
     
  7. Family History – Include relevant information.

  8. Physical Examination – Describe and discuss (when appropriate):
    1. General appearance, nutritional status (including height and weight without shoes), behavior (such as cooperativeness), any apparent abnormalities (such as, muscle wasting);
    2. The vital signs must include temperature, blood pressure, pulse rate and rhythm, respiratory rate (and whether unlabored or labored, and if there is use of accessory muscles of respiration)
    3. Affected organ-system examination to enable assessment of severity of such involvement (for example, ascitic fluid, peripheral edema, mental status, asterixis, abdominal organomegaly, abdominal masses, orthodeoxia, platypnea); abdominal masses, rectal bleeding, superficial manifestations of liver disease – spider angiomas, caput medusae, altered venous flow on the abdomen.

  9. Interpretation of laboratory tests (If the interpretation is provided separately, the report sheet should state the interpreting medical source's name and address)
    1. Identify the medical source (name and address) providing the formal interpretation of the laboratory tests when that source is other than the individual signing the CE report.
    2. Provide interpretation of laboratory results that takes into account, and correlates with, the history and physical examination findings.

  10. Imaging tests (for example, x-rays) and other laboratory tests – Obtain only after proper authorization from the DDS.

  11. Medical source statement – The consultative examiner must assess the claimant’s abilities and limitations based upon the claimant’s medical history, observations during the examination, and results of relevant laboratory tests. The medical source statement should specify the nature and extent of the condition or disorder. It must also discuss any apparent discrepancies in the medical history or in the examination findings. Finally, the statement must specify any limitations in function that result from the condition or disorder, including:
  • Lifting/carrying/pushing/pulling
  • Sitting/standing/walking
  • Posture (for example, climbing/stooping/bending/balancing/crawling/ kneeling/crouching)
  • Fine motor skills (that is, handling/fingering/gripping/feeling)
  • Overhead and forward reaching
  • Vision/hearing/speech
  • Environmental exposures (for example, heat/cold/humidity/noise/vibration)

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Genitourinary Impairments

(Boldface type indicates additional requirements not found in the General Report)

  1. General
    1. Identify claimant
      1. Include the claimant’s claim number, and
      2. Indicate that the claimant provided proof of identity by showing a valid and current government photo ID (e.g., U.S. State-issued driver’s license, U.S. State-issued non-driver identity card, U.S. passport, U.S. military ID, student or school ID, etc.) or
      3. Provide a physical description of the claimant, to help ensure that the person being examined is the claimant, except if the treating source is the CE source. 
    2. Longitudinal medical history
      1. Cite the medical records and any other documents reviewed during the course of the evaluation.
      2. Identify the person(s) providing the oral medical history and an assessment of the validity and reliability of such information.

  2. Current Medical History – Describe and discuss (when appropriate):
    1. The primary symptom(s) alleged as the reason for not working. This discussion must include:
      1. History of the onset and progress of the disorder;
      2. The claimant's statement of current symptom(s), especially fatigue, dyspnea, motor weakness, sensory aberrations, loss of appetite;
      3. Type and resultant effect of any treatment;
      4. Claimant’s typical daily activities.
    2. Dates and results of relevant hospitalizations, surgical operations, and diagnostic procedures (for example, imaging studies, clinical laboratory tests), frequency of any renal dialysis.

  3. Past Medical History – Describe and discuss (when appropriate) other significant past illnesses, injuries, operations, and diagnostic procedures with dates of the events.

  4. Current Medication – List name, dose and frequency of medication(s), including both beneficial and adverse effects.
     
  5. Review of Systems – Describe and discuss:
    1. Other symptoms the claimant has experienced relative to any specific organ systems;
    2. The pertinent negative findings considered in making a differential diagnosis of the current illness or in evaluating the severity of this or any other alleged impairment.
       
  6. Social History – Include pertinent findings about use of tobacco products, alcohol, nonprescription drugs, etc.
     
  7. Family History – Include relevant information.

  8. Physical Examination – Describe and discuss (when appropriate):
    1. General appearance, nutritional status (including height and weight without shoes), behavior (such as cooperativeness), any apparent abnormalities;
    2. The vital signs must include temperature, blood pressure, pulse rate and rhythm, respiratory rate (and whether unlabored or labored, and if there is use of accessory muscles of respiration);
    3. Renal osteodystrophy, ascites, pleural effusion, edema (type and location), and any signs of cardiac involvement.

  9. Interpretation of laboratory tests (If the interpretation is provided separately, the report sheet should state the interpreting medical source's name and address)
    1. Identify the medical source (name and address) providing the formal interpretation of the laboratory tests when that source is other than the individual signing the CE report.
    2. Provide interpretation of laboratory results that takes into account, and correlates with, the history and physical examination findings.

  10. Imaging tests (for example, x-rays) and other laboratory tests – Obtain only after proper authorization from the DDS.

  11. Medical source statement – The consultative examiner must assess the claimant’s abilities and limitations based upon the claimant’s medical history, observations during the examination, and results of relevant laboratory tests. The medical source statement should specify the nature and extent of the condition or disorder. It must also discuss any apparent discrepancies in the medical history or in the examination findings. Finally, the statement must specify any limitations in function that result from the condition or disorder, including:
  • Lifting/carrying/pushing/pulling
  • Sitting/standing/walking
  • Posture (for example, climbing/stooping/bending/balancing/crawling/ kneeling/crouching)
  • Fine motor skills (that is, handling/fingering/gripping/feeling)
  • Overhead and forward reaching
  • Vision/hearing/speech
  • Environmental exposures (for example, heat/cold/humidity/noise/vibration)

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Hematological Disorders

(Boldface type indicates additional requirements not found in the General Report)

  1. General
    1. Identify claimant
      1. Include the claimant’s claim number, and
      2. Indicate that the claimant provided proof of identity by showing a valid and current government photo ID (e.g., U.S. State-issued driver’s license, U.S. State-issued non-driver identity card, U.S. passport, U.S. military ID, student or school ID, etc.) or
      3. Provide a physical description of the claimant, to help ensure that the person being examined is the claimant, except if the treating source is the CE source.
    2. Longitudinal medical history
      1. Cite the medical records and any other documents reviewed during the course of the evaluation.
      2. Identify the person(s) providing the oral medical history and an assessment of the validity and reliability of such information.

  2. Current Medical History – Describe and discuss (when appropriate):
    1. The primary symptom(s) alleged as the reason for not working. This discussion must include:
      1. History of the onset and progress of the disorder, including abnormal blood clotting, pain crises, infections, frequency of RBC or other blood component transfusions/infusions;
      2. The claimant's statement of current symptom(s);
      3. Type and resultant effect of any treatment;
      4. Claimant’s typical daily activities.
    2. Dates and results of relevant hospitalizations, surgical operations, and diagnostic procedures (for example, CBC, platelets, reticulocyte count, serial hemoglobins, hemoglobin electrophoresis, blood smears, bone marrow examination).

  3. Past Medical History – Describe and discuss (when appropriate) other significant past illnesses, injuries, operations, and diagnostic procedures with dates of the events.

  4. Current Medication – List name, dose and frequency of medication(s), including both beneficial and adverse effects.
     
  5. Review of Systems – Describe and discuss:
    1. Other symptoms the claimant has experienced relative to any specific organ systems;
    2. The pertinent negative findings considered in making a differential diagnosis of the current illness or in evaluating the severity of this or any other alleged impairment.
       
  6. Social History – Include pertinent findings about use of tobacco products, alcohol, nonprescription drugs, etc.
     
  7. Family History – Include relevant information.

  8. Physical Examination – Describe and discuss (when appropriate):
    1. General appearance, nutritional status (including height and weight without shoes), behavior (such as cooperativeness), any apparent abnormalities (such as, pallor, jaundice, abnormal bruising, petechiae, ecchymoses, edema, fatigue level, enlarged lymph nodes);
    2. The vital signs must include blood pressure (taken supine, sitting, and standing if the claimant alleges syncope or near-syncope), pulse rate and rhythm, respiratory rate (and whether unlabored or labored, and if there is use of accessory muscles of respiration);
    3. Joint examinations, including swelling, tenderness, bleeding, and range of motion;
    4. Abdominal examination, including liver, spleen, or abnormal masses
    5. General and focal neurologic, and mental status examination.

  9. Interpretation of laboratory tests (If the interpretation is provided separately, the report sheet should state the interpreting medical source's name and address)
    1. Identify the medical source (name and address) providing the formal interpretation of the laboratory tests when that source is other than the individual signing the CE report.
    2. Provide interpretation of laboratory results that takes into account, and correlates with, the history and physical examination findings.

  10. Imaging tests (for example, x-rays) and other laboratory tests – Obtain only after proper authorization from the DDS.

  11. Medical source statement – The consultative examiner must assess the claimant’s abilities and limitations based upon the claimant’s medical history, observations during the examination, and results of relevant laboratory tests. The medical source statement should specify the nature and extent of the condition or disorder. It must also discuss any apparent discrepancies in the medical history or in the examination findings. Finally, the statement must specify any limitations in function that result from the condition or disorder, including:
  • Lifting/carrying/pushing/pulling
  • Sitting/standing/walking
  • Posture (for example, climbing/stooping/bending/balancing/crawling/ kneeling/crouching)
  • Fine motor skills (that is, handling/fingering/gripping/feeling)
  • Overhead and forward reaching
  • Vision/hearing/speech
  • Environmental exposures (for example, heat/cold/humidity/noise/vibration)
  1. Additional Information – Any other Body system considerations (for example, musculoskeletal, resulting from joint problems associated with hemophilia or sickle cell disease).

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Skin Disorders

(Boldface type indicates additional requirements not found in the General Report)

  1. General
    1. Identify claimant
      1. Include the claimant’s claim number, and
      2. Indicate that the claimant provided proof of identity by showing a valid and current government photo ID (e.g., U.S. State-issued driver’s license, U.S. State-issued non-driver identity card, U.S. passport, U.S. military ID, student or school ID, etc.) or
      3. Provide a physical description of the claimant, to help ensure that the person being examined is the claimant, except if the treating source is the CE source. 
    2. Longitudinal medical history
      1. Cite the medical records and any other documents reviewed during the course of the evaluation.
      2. Identify the person(s) providing the oral medical history and an assessment of the validity and reliability of such information.

  2. Current Medical History – Describe and discuss (when appropriate):
    1. The primary symptom(s) alleged as the reason for not working. This discussion must include:
      1. History of the onset and progress of the disorder;
      2. The claimant's statement of current symptom(s);
      3. Type and resultant effect of any treatment;
      4. Claimant’s typical daily activities.
    2. Dates and results of relevant hospitalizations, surgical operations, and diagnostic procedures (for example, biopsy, genetic testing).

  3. Past Medical History – Describe and discuss (when appropriate) other significant past illnesses, injuries, operations, and diagnostic procedures with dates of the events.

  4. Current Medication – List name, dose and frequency of medication(s), including both beneficial and adverse effects; and plans for continued drug administration, schedule and extent of any therapy.
     
  5. Review of Systems – Describe and discuss:
    1. Other symptoms the claimant has experienced relative to any specific organ systems;
    2. The pertinent negative findings considered in making a differential diagnosis of the current illness or in evaluating the severity of this or any other alleged impairment.
       
  6. Social History – Include pertinent findings about use of tobacco products, alcohol, nonprescription drugs, etc.
     
  7. Family History – Include relevant information.

  8. Physical Examination – Describe and discuss (when appropriate):
    1. General appearance, nutritional status (including height and weight without shoes), behavior (such as cooperativeness), any apparent abnormalities;
    2. Detailed description of skin lesions, including type of lesion and extent of the body affected; interference in joint function with range of motion of affected joint(s).
    3. You may take a digital photograph to submit with your report to document the severity of the claimant’s skin lesions.
  1. Interpretation of laboratory tests (If the interpretation is provided separately, the report sheet should state the interpreting medical source's name and address)
    1. Identify the medical source (name and address) providing the formal interpretation of the laboratory tests when that source is other than the individual signing the CE report.
    2. Provide interpretation of laboratory results that takes into account, and correlates with, the history and physical examination findings.

  2. Imaging tests (for example, x-rays) and other laboratory tests – Obtain only after proper authorization from the DDS.

  3. Medical source statement – The consultative examiner must assess the claimant’s abilities and limitations based upon the claimant’s medical history, observations during the examination, and results of relevant laboratory tests. The medical source statement should specify the nature and extent of the condition or disorder. It must also discuss any apparent discrepancies in the medical history or in the examination findings. Finally, the statement must specify any limitations in function that result from the condition or disorder, including:
  • Lifting/carrying/pushing/pulling
  • Sitting/standing/walking
  • Posture (for example, climbing/stooping/bending/balancing/crawling/ kneeling/crouching)
  • Fine motor skills (that is, handling/fingering/gripping/feeling)
  • Overhead and forward reaching
  • Vision/hearing/speech
  • Environmental exposures (for example, heat/cold/humidity/noise/vibration)

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Endocrine Disorders

(Boldface type indicates additional requirements not found in the General Report)

  1. General
    1. Identify claimant
      1. Include the claimant’s claim number, and
      2. Indicate that the claimant provided proof of identity by showing a valid and current government photo ID (e.g., U.S. State-issued driver’s license, U.S. State-issued non-driver identity card, U.S. passport, U.S. military ID, student or school ID, etc.) or
      3. Provide a physical description of the claimant, to help ensure that the person being examined is the claimant, except if the treating source is the CE source. 
    2. Longitudinal medical history
      1. Cite the medical records and any other documents reviewed during the course of the evaluation.
      2. Identify the person(s) providing the oral medical history and an assessment of the validity and reliability of such information.

  2. Current Medical History – Describe and discuss (when appropriate):
    1. The primary symptom(s) alleged as the reason for not working. This discussion must include:
      1. History of the onset and progress of the disorder;
      2. The claimant's statement of current symptom(s), especially heat or cold intolerance, sensory aberrations, motor function, visual disorder;
      3. Type and resultant effect of any treatment;
      4. Claimant’s typical daily activities;
      5. Convulsions, tetany, or episodes of alteration of consciousness
      6. Bone pain or localization of pain
      7. Abnormal bowel or urinary tract changes, including change in frequency.
    2. Dates and results of relevant hospitalizations, surgical operations, and diagnostic procedures (for example, CBC; liver enzymes; adrenal function; serum electrolytes, calcium and phosphorus; fasting blood glucose, glucose tolerance testing, Hb1AC, blood chemistries, T3, TSH, urinalysis, relevant imaging studies).

  3. Past Medical History – Describe and discuss (when appropriate) other significant past illnesses, injuries, operations, and diagnostic procedures with dates of the events.

  4. Current Medication – List name, dose and frequency of medication(s), including both beneficial and adverse effects.
     
  5. Review of Systems – Describe and discuss:
    1. Other symptoms the claimant has experienced relative to any specific organ systems;
    2. The pertinent negative findings considered in making a differential diagnosis of the current illness or in evaluating the severity of this or any other alleged impairment.
       
  6. Social History – Include pertinent findings about use of tobacco products, alcohol, nonprescription drugs, etc.
     
  7. Family History – Include relevant information.

  8. Physical Examination – Describe and discuss (when appropriate):
    1. General appearance, nutritional status (including height and weight without shoes), behavior (such as cooperativeness), any apparent abnormalities;
    2. The vital signs must include blood pressure (taken supine, sitting, and standing), pulse rate and rhythm, respiratory rate (and whether unlabored or labored, and if there is use of accessory muscles of respiration);
    3. Abnormal sweating, dry skin, or changes in color or texture of skin;
    4. Abnormal eye changes, such as exophthalmia, cataracts, visual fields, optic nerve, extra ocular muscle movement and fundus changes (retinitis proliferens);
    5. Mental status;
    6. Presence of Chvostek or Trousseau signs;
    7. Peripheral neuropathy, both sensory and motor;
    8. Abnormal masses of neck or abdomen.

  9. Interpretation of laboratory tests (If the interpretation is provided separately, the report sheet should state the interpreting medical source's name and address)
    1. Identify the medical source (name and address) providing the formal interpretation of the laboratory tests when that source is someone other than the individual signing the CE report.
    2. Provide interpretation of laboratory results that takes into account, and correlates with, the history and physical examination findings.

  10. Imaging tests (for example, x-rays) and other laboratory tests – Obtain only after proper authorization from the DDS.

  11. Medical source statement – The consultative examiner must assess the claimant’s abilities and limitations based upon the claimant’s medical history, observations during the examination, and results of relevant laboratory tests. The medical source statement should specify the nature and extent of the condition or disorder. It must also discuss any apparent discrepancies in the medical history or in the examination findings. Finally, the statement must specify any limitations in function that result from the condition or disorder, including:
  • Lifting/carrying/pushing/pulling
  • Sitting/standing/walking
  • Posture (for example, climbing/stooping/bending/balancing/crawling/ kneeling/crouching)
  • Fine motor skills (that is, handling/fingering/gripping/feeling)
  • Overhead and forward reaching
  • Vision/hearing/speech
  • Environmental exposures (for example, heat/cold/humidity/noise/vibration)

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Neurological Disorders

(Boldface type indicates additional requirements not found in the General Report)

  1. General
    1. Identify claimant
      1. Include the claimant’s claim number, and
      2. Indicate that the claimant provided proof of identity by showing a valid and current government photo ID (e.g., U.S. State-issued driver’s license, U.S. State-issued non-driver identity card, U.S. passport, U.S. military ID, student or school ID, etc.) or
      3. Provide a physical description of the claimant, to help ensure that the person being examined is the claimant, except if the treating source is the CE source.
    2. Longitudinal medical history
      1. Cite the medical records and any other documents reviewed during the course of the evaluation.
      2. Identify the person(s) providing the oral medical history and an assessment of the validity and reliability of such information.

  2. Current Medical History – Describe and discuss (when appropriate):
    1. The primary symptom(s) alleged as the reason for not working. This discussion must include:
      1. History of the onset and progress of the disorder;
      2. The claimant's statement of current symptom(s), especially cognitive impairment; motor weakness; sensory aberrations; problems with speech, swallowing, voiding and defecation;
      3. Give a complete description of seizures including type and severity; diurnal or nocturnal, frequency per month during the past year, duration of episodes and postictal phenomena.
      4. Dates of claimant’s last three seizures;
      5. Type and resultant effect of any treatment; claimant’s cooperation with taking medication as prescribed;
      6. Claimant’s typical daily activities.
    2. Dates and results of relevant hospitalizations, surgical operations, and diagnostic procedures (for example, imaging studies, EEGs).

  3. Past Medical History – Describe and discuss (when appropriate) other significant past illnesses, injuries, operations, and diagnostic procedures with dates of the events.

  4. Current Medication – List name, dose and frequency of medication(s), including both beneficial and adverse effects.
     
  5. Review of Systems – Describe and discuss:
    1. Other symptoms the claimant has experienced relative to any specific organ systems;
    2. The pertinent negative findings considered in making a differential diagnosis of the current illness or in evaluating the severity of this or any other alleged impairment.
       
  6. Social History – Include pertinent findings about use of tobacco products, alcohol, nonprescription drugs, etc.
     
  7. Family History – Include relevant information.

  8. Physical Examination – Describe and discuss (when appropriate):
    1. General appearance, nutritional status (including height and weight without shoes), behavior (such as cooperativeness), any apparent abnormalities;
    2. The vital signs must include blood pressure (taken supine, sitting, and standing), pulse rate and rhythm, respiratory rate (and whether unlabored or labored, and if there is use of accessory muscles of respiration)
    3. Mobility, including hand dominance; ability to use the upper extremities effectively for gross and fine movements; ability to arise from a seated position, stand; walk (with and without assistance); get on and off the examination table; abnormal movements (especially tremors and incoordination); heel, toe and tandem walk
    4. Motor function, including strength (dynamometer or 0 – 5), atrophy, spasticity, rigidity, limitation of movement, fatigability of extremities, reflexes (deep tendon and superficial);
    5. In cases where fatigue is alleged and especially in cases where myasthenia gravis is alleged, test for ability to fatigue the claimant by exercise (for example, ptosis develops after 1 minute of attempted up gaze or strength declines from 5/5 at rest to 2/5 after 10 minutes of exercise of a particular muscle).
    6. Cranial nerve functions (especially pupillary responses to light and accommodation, visual acuity, visual fields to confrontation, extraocular movements)
    7. Sensory function, including pattern (anatomic/non-anatomic) and characteristics of any pain (and relationship to underlying disorder)
    8. Mental and speech function, including mental status (Mini Mental Test), evidence of emotional disorder/lability, aphasia, stuttering, dysarthria, intelligibility of speech.

  9. Interpretation of laboratory tests (If the interpretation is provided separately, the report sheet should state the interpreting medical source's name and address)
    1. Identify the medical source (name and address) providing the formal interpretation of the laboratory tests when that source is other than the individual signing the CE report.
    2. Provide interpretation of laboratory results that takes into account, and correlates with, the history and physical examination findings.

  10. Imaging tests (for example, x-rays) and other laboratory tests – Obtain only after proper authorization from the DDS.

  11. Medical source statement – The consultative examiner must assess the claimant’s abilities and limitations based upon the claimant’s medical history, observations during the examination, and results of relevant laboratory tests. The opinion statement should specify the nature and extent of the condition or disorder. It must also discuss any apparent discrepancies in the medical history or examination findings. Finally, the opinion statement must specify any limitations in function that result from the condition or disorder, including:
  • Lifting/carrying/pushing/pulling
  • Sitting/standing/walking
  • Posture (for example, climbing/stooping/bending/balancing/crawling/ kneeling/crouching)
  • Fine motor skills (that is, handling/fingering/gripping/feeling)
  • Overhead and forward reaching
  • Vision/hearing/speech
  • Environmental exposures (for example, heat/cold/humidity/noise/vibration)

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Mental Disorders

(Boldface type indicates additional requirements not found in the General Report)

  1. General
    1. Identify claimant
      1. Include the claimant’s claim number, and
      2. Indicate that the claimant provided proof of identity by showing a valid and current government photo ID (e.g., U.S. State-issued driver’s license, U.S. State-issued non-driver identity card, U.S. passport, U.S. military ID, student or school ID, etc.) or
      3. Provide a physical description of the claimant, to help ensure that the person being examined is the claimant, except if the treating source is the CE source.
    2. Longitudinal medical history
      1. Cite the medical records and any other documents reviewed during the course of the evaluation.
      2. Identify the person(s) providing the oral medical history and an assessment of the accuracy of such information.

  2. Current Medical History – Describe and discuss:
    1. The primary symptom(s) alleged as the reason for not working. This discussion must include:
      1. History of the onset and progress of the disorder;
      2. The claimant's statement of current symptom(s);
      3. Type(s) and effect(s) of any treatment;
      4. Claimant’s typical daily activities.
    2. Dates and results of relevant hospitalizations, surgical operations, and diagnostic procedures.
    3. Past and current participation and success or failure in rehabilitation, group homes or half-way houses, inpatient or outpatient treatment.
  1. Past Medical History – Describe and discuss (when appropriate) other significant past illnesses, injuries, operations, and diagnostic procedures with dates of the events.

  2. Current Medication – List name, dose and frequency of medication(s); including both beneficial and adverse effects.

  3. Social and Family History – Include the following:
    1. Relevant information, including longitudinal history of relations with parents, family, peers, spouses, co-workers, etc.;
    2. Educational background (special education, college courses/degree, special vocational training);
    3. Relevant history of legal or occupational problems associated with the disorder;
    4. Involvement in hobbies and/or regular group activities (church, social clubs, participation in sports teams, etc.);
    5. A description of the claimant’s attempt(s) to return to work and the results (e.g., de-compensation, missed work due to inability to handle stress);
    6. Detailed longitudinal discussion of any history of alcohol, licit and illicit drug abuse, and comments on the effects of substance abuse on functioning; if there is no history of substance abuse, include a statement to that effect.

  4. Physical Examination – Describe and discuss (when appropriate):
    1.  General appearance, nutritional status, behavior (such as cooperativeness), any apparent abnormalities;
    2. General observations, including whether the claimant came to the examination alone or accompanied; distance and mode of transportation; and, if by automobile, who drove;
    3. General motor behavior, including involuntary movements, restlessness, and psychomotor retardation or agitation.

  5. Mental Status Evaluation Include the following specific observations:
    1. Manner and approach to evaluation;
    2. Dress, grooming, hygiene and presentation;
    3. Mood and affect;
    4. Eye contact;
    5. Expressive/receptive language;
    6. Recall/memory, including working, recent and remote;
    7. Orientation in all 4 spheres;
    8. Concentration and attention;
    9. Thought processes and content;
    10. Perceptual abnormalities;
    11. Suicidal/homicidal ideation;
    12. Judgment/insight;
    13. Estimated level of intelligence.

  6. Interpretation of psychological and/or clinical testing. (If the interpretation is provided separately, the report sheet should state the interpreting medical source's name and address)
    1. Identify the medical source (name and address) providing the formal interpretation of the psychological and/or clinical tests when that source is other than the individual signing the CE report.
    2. Provide interpretation of psychological and/or clinical testing results that takes into account, and correlates with, the history and examination findings.
  1. Additional Information – the report should also contain the following:
    1. A full multiaxial classification per American Psychiatric Association standard nomenclature as set forth in the most recent Diagnostic and Statistical Manual of Mental Disorders
    2. Prognosis and recommendations for treatment, if indicated. Also, recommendations for any other evaluation (for example, neurological examination), if needed
    3.  For claimants with intellectual impairment:
      1. Current documentation of IQ by a standardized, well-recognized, individually administered measure. Acceptable instruments will have a recent and representative normative sample of the target population, a mean of approximately 100 and standard deviation of approximately 15 in the general population, and cover a broad range of cognitive and perceptual-motor functions.
      2. Verbal IQ, Performance IQ, and Full Scale IQ scores, or their equivalents, together with the individual subtest scores.
      3. Interpretation of the scores and assessment of the validity of the obtained scores, indicating any factors that influenced the claimant's attitude or degree of cooperation.
      4. Consistency of the obtained test results with the claimant's educational, vocational, and social background.
      5. A comprehensive and detailed description of adaptive behavior in the areas of personal, social, academic, and occupational functioning during the developmental period.

  2. Medical source statement – Include the following:
    1. A statement regarding the nature and extent of the mental disorder.
    2. An assessment of the claimant’s abilities and limitations based on medical history, observations during examination, and results of relevant laboratory tests; and an opinion regarding the ability to:
      1. Understand, carry out, and remember instructions (both complex and one-two step);
      2. Sustain concentration and persist in work-related activity at reasonable pace;
      3. Maintain effective social interaction on a consistent and independent basis, with supervisors, co-workers, and the public; and
      4. Deal with normal pressures in a competitive work setting.

    3. If hazards should be avoided or limited (e.g., operating machinery due to medication side effect), specify which ones and why. 
    4. Discussion of any apparent discrepancies in medical history or in examination findings and how discrepancies resolved.
    5. A statement regarding malingering, if applicable.
    6. A statement regarding the capability to manage funds.

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Malignant Neoplastic Diseases

(Boldface type indicates additional requirements not found in the General Report)

  1. General
    1. Identify claimant
      1. Include the claimant’s claim number, and
      2. Indicate that the claimant provided proof of identity by showing a valid and current government photo ID (e.g., U.S. State-issued driver’s license, U.S. State-issued non-driver identity card, U.S. passport, U.S. military ID, student or school ID, etc.) or
      3. Provide a physical description of the claimant, to help ensure that the person being examined is the claimant, except if the treating source is the CE source.
    2. Longitudinal medical history
      1. Cite the medical records and any other documents reviewed during the course of the evaluation.
      2. Identify the person(s) providing the oral medical history and an assessment of the validity and reliability of such information.

  2. Current Medical History – Describe and discuss (when appropriate):
    1. The primary symptom(s) alleged as the reason for not working. This discussion must include:
      1. History of the onset and progress of the disorder;
      2. The claimant's statement of current symptom(s), including fatigue, malaise, affected organ-system symptoms;
      3. Type and resultant effect of any treatment; specifically, response to therapy (surgical, radiation, chemotherapy) and effects of any post-therapeutic residuals;
      4. Claimant’s typical daily activities.
      5. Specify current or planned treatment including chemotherapy/radiation/hormonal therapy and response to such with results of follow-up imaging studies.
      6. Weight loss as a specific symptom.
      7. Prognosis, if available, as stated in treating source reports.
    2. Dates and results of relevant hospitalizations, surgical operations, and diagnostic procedures (for example, biopsy or tissue pathologic examination, imaging studies).

  3. Past Medical History – Describe and discuss (when appropriate) other significant past illnesses, injuries, operations, and diagnostic procedures with dates of the events.

  4. Current Medication – List name, dose and frequency of medication(s), including both beneficial and adverse effects.
     
  5. Review of Systems – Describe and discuss:
    1. Other symptoms the claimant has experienced relative to any specific organ systems;
    2. The pertinent negative findings considered in making a differential diagnosis of the current illness or in evaluating the severity of this or any other alleged impairment.
       
  6. Social History – Include pertinent findings about use of tobacco products, alcohol, nonprescription drugs, etc.
     
  7. Family History – Include relevant information.

  8. Physical Examination – Describe and discuss (when appropriate):
    1. General appearance, nutritional status (including height and weight without shoes), behavior (such as cooperativeness), any apparent abnormalities;
    2. The vital signs must include temperature, blood pressure, pulse rate and rhythm, respiratory rate (and whether unlabored or labored, and if there is use of accessory muscles of respiration)
    3. A complete physical examination in order to evaluate the effect of both the cancer and its treatment on the claimant.

  9. Interpretation of laboratory tests (If the interpretation is provided separately, the report sheet should state the interpreting medical source's name and address)
    1. Identify the medical source (name and address) providing the formal interpretation of the laboratory tests when that source is other than the individual signing the CE report.
    2. Provide interpretation of laboratory results that takes into account, and correlates with, the history and physical examination findings.

  10. Imaging tests (for example, x-rays) and other laboratory tests – Obtain only after proper authorization from the DDS.
  1. Medical source statement – The consultative examiner must assess the claimant’s abilities and limitations based upon the claimant’s medical history, observations during the examination, and results of relevant laboratory tests. The medical source statement should specify the nature and extent of the condition or disorder. It must also discuss any apparent discrepancies in the medical history or in the examination findings. Finally, the statement must specify any limitations in function that result from the condition or disorder, including:
  • Lifting/carrying/pushing/pulling
  • Sitting/standing/walking
  • Posture (for example, climbing/stooping/bending/balancing/crawling/ kneeling/crouching)
  • Fine motor skills (that is, handling/fingering/gripping/feeling)
  • Overhead and forward reaching
  • Vision/hearing/speech
  • Environmental exposures (for example, heat/cold/humidity/noise/vibration)
  1. Additional Information – Any other Body System considerations (for example, cardiovascular, neurological, etc., affected by treatment adverse effects).

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Immune System Disorders

(Boldface type indicates additional requirements not found in the General Report)

  1. General
    1. Identify claimant
      1. Include the claimant’s claim number, and
      2. Indicate that the claimant provided proof of identity by showing a valid and current government photo ID (e.g., U.S. State-issued driver’s license, U.S. State-issued non-driver identity card, U.S. passport, U.S. military ID, student or school ID, etc.) or
      3. Provide a physical description of the claimant, except if the treating source is the CE source. 
    2. Longitudinal medical history
      1. Cite the medical records and any other documents reviewed during the course of the evaluation. State whether the DDS provided medical documents for review.
      2. Identify the person(s) providing the oral medical history and an assessment of the validity and reliability of such information.

  2. Current Medical History – Describe and discuss (when appropriate):
    1. The primary symptom(s) alleged as the reason for not working. This discussion must include:
      1. History of the onset, diagnostic criteria, and progress of the disorder;
      2. The claimant's statement of current symptom(s), especially as related to the affected organ(s); also include weight loss, fever, pain, fatigue, and malaise;
      3. Type and resultant effect of any treatment;
      4. Claimant’s typical daily activities;
      5. Degree of limitation, if any, of activities of daily living, maintenance of social functioning, completion of tasks in a timely manner due to deficiencies in concentration, persistence, or pace;
      6. Symptoms related to specific organ-system involvement.
    2. Dates and results of relevant hospitalizations, surgical operations, and diagnostic procedures, weight loss and fever.

  3. Past Medical History – Describe and discuss (when appropriate) other significant past illnesses, injuries, operations, and diagnostic procedures with dates of the events.

  4. Current Medication – List name, dose and frequency of medication(s), including both beneficial and adverse effects.
  1. Review of Systems – Describe and discuss:
    1. Other symptoms the claimant has experienced relative to any specific organ systems; these symptoms should be related to the allegation; however, conditions such as HIV infection may affect different organs.  Note the duration of the symptoms.
    2. The pertinent negative findings considered in making a differential diagnosis of the current illness or in evaluating the severity of this or any other alleged impairment.
       
  2. Social History – Include pertinent findings about use of tobacco products, alcohol, nonprescription drugs, etc.
     
  3. Family History – Include relevant information.

  4. Physical Examination – Describe and discuss (when appropriate):
    1. General appearance, nutritional status (including height and weight without shoes), behavior (such as cooperativeness), any apparent abnormalities;
    2. The vital signs must include temperature, blood pressure, pulse rate and rhythm, respiratory rate (and whether unlabored or labored, and if there is use of accessory muscles of respiration)
    3. Affected organ-system examination to enable assessment of severity of such involvement (for example, joint function in rheumatoid arthritis).

  5. Interpretation of laboratory tests (If the interpretation is provided separately, the report sheet should state the interpreting medical source's name and address)
    1. Identify the medical source (name and address) providing the formal interpretation of the laboratory tests when that source is other than the individual signing the CE report.
    2. Provide interpretation of laboratory results that takes into account, and correlates with, the history and physical examination findings.

  6. Imaging tests (for example, x-rays) and other laboratory tests – Obtain only after proper authorization from the DDS.

  7. Additional Information – Objective measures of functioning necessary to accurately assess limitations of activities of daily living, in maintaining social functioning and in completing tasks in a timely manner; provide rationale for any conclusions;

  8. Medical source statement – The consultative examiner must assess the claimant’s abilities and limitations based upon the claimant’s medical history, observations during the examination, and results of relevant laboratory tests. The medical source statement should specify the nature and extent of the condition or disorder. It must also discuss any apparent discrepancies in the medical history or in the examination findings. Finally, the statement must specify any limitations in function that result from the condition or disorder, including:
  • Lifting/carrying/pushing/pulling
  • Sitting/standing/walking
  • Posture (for example, climbing/stooping/bending/balancing/crawling/ kneeling/crouching)
  • Fine motor skills (that is, handling/fingering/gripping/feeling)
  • Overhead and forward reaching
  • Vision/hearing/speech
  • Environmental exposures (for example, heat/cold/humidity/noise/vibration)